I Am a Racially Profiling Doctor

By Sally Satel

Published: May 5, 2002

In practicing medicine, I am not colorblind. I always take note of my patient's race. So do many of my colleagues. We do it because certain diseases and treatment responses cluster by ethnicity. Recognizing these patterns can help us diagnose disease more efficiently and prescribe medications more effectively. When it comes to practicing medicine, stereotyping often works.

But to a growing number of critics, this statement is viewed as a shocking admission of prejudice. After all, shouldn't all patients be treated equally, regardless of the color of their skin? The controversy came to a boil last May in The New England Journal of Medicine. The journal published a study revealing that enalapril, a standard treatment for chronic heart failure, was less helpful to blacks than to whites. Researchers found that significantly more black patients treated with enalapril ended up hospitalized. A companion study examined carvedilol, a beta blocker; the results indicated that the drug was equally beneficial to both races.

These clinically important studies were accompanied, however, by an essay titled ''Racial Profiling in Medical Research.'' Robert S. Schwartz, a deputy editor at the journal, wrote that prescribing medication by taking race into account was a form of ''race-based medicine'' that was both morally and scientifically wrong. ''Race is not only imprecise but also of no proven value in treating an individual patient,'' Schwartz wrote. ''Tax-supported trolling . . . to find racial distinctions in human biology must end.''

Responding to Schwartz's essay in The Chronicle of Higher Education, other doctors voiced their support. ''It's not valid science,'' charged Richard S. Cooper, a hypertension expert at Loyola Medical School. ''I challenge any member of our species to show where this kind of analysis has come up with something useful.''

But the enalapril researchers were doing something useful. Their study informed thousands of doctors that, when it came to their black patients, one drug was more likely to be effective than another. The study may have saved some lives. What's more useful than that?

Almost every day at the Washington drug clinic where I work as a psychiatrist, race plays a useful diagnostic role. When I prescribe Prozac to a patient who is African-American, I start at a lower dose, 5 or 10 milligrams instead of the usual 10-to-20 milligram dose. I do this in part because clinical experience and pharmacological research show that blacks metabolize antidepressants more slowly than Caucasians and Asians. As a result, levels of the medication can build up and make side effects more likely. To be sure, not every African-American is a slow metabolizer of antidepressants; only 40 percent are. But the risk of provoking side effects like nausea, insomnia or fuzzy-headedness in a depressed person -- someone already terribly demoralized who may have been reluctant to take medication in the first place -- is to worsen the patient's distress and increase the chances that he will flush the pills down the toilet. So I start all black patients with a lower dose, then take it from there.

In my drug-treatment clinic, where almost all of the patients use heroin by injection, a substantial number of them have hepatitis C, an infectious blood-borne virus that now accounts for 40 percent of all chronic liver disease. The standard treatment for active hepatitis C is an antiviral-drug combination of alpha interferon and ribavirin. But for some as yet undiscovered reason, African-Americans do not respond as well as whites to this regimen. In white patients, the double therapy reduces the amount of virus in the blood by over 90 percent after six months of treatment. In blacks, the reduction is only 50 percent. As a result, my black patients with hepatitis C must be given a considerably less reassuring prognosis than my white patients.

Without a doubt, there are many medical situations in which race is irrelevant. In an operation to repair a broken leg, for example, a patient's race doesn't matter. But there are countless situations in which the race factor should be considered. My colleague Ronald W. Dworkin, an anesthesiologist in a Baltimore-area hospital, takes race into account when performing one of his most important activities: intubation, the placement of a breathing tube down a patient's windpipe. During intubation, he says, black patients tend to salivate heavily, which can cause airway complications. As a precautionary measure, Dworkin gives many of his black patients a drying agent. ''Not every black person fits this observation,'' he concedes, ''but there is sufficient empirical evidence to make every anesthesiologist keep this danger in the back of his or her mind.'' The day I spoke with him, Dworkin attended a hysterectomy in a middle-aged Asian woman. ''Asians tend to have a greater sensitivity to narcotics,'' he says, ''so we always start with lower doses. They run the risk of apnea'' -- the cessation of breathing -- if we do not.''